Severe Equinovarus deformities and ambulation: RESPONSES page 1
Randy McFarland
Description
Collection
Title:
Severe Equinovarus deformities and ambulation: RESPONSES page 1
Creator:
Randy McFarland
Date:
1/10/2016
Text:
ORIGINAL POST:
I have a patient who has developed severe equino varus deformities
bilaterally which we were unable to correct with dynamic AFOs.
She is in a SNF and is alert and still wants to ambulate and would benefit
from weight bearing and exercise, but her deformities preclude traditional
AFOs. I am wondering if anyone if any of you have tried making total contact
well-padded AFOs to accommodate the deformities with modified soles to allow
weight bearing/ standing and very limited walking. She is not diabetic. Of
course the skin would need to be monitored closely and she would need
assistance standing and would require an assistive device to balance and
ambulate. Please let me know if any of you have attempted such a fitting
experiment. I have significant reservations not to mention doubts regarding
receiving payment. Thanks, Randy McFarland, CPO Fullerton, CA
RESPONSES: Thanks to contributors!
I have a past patient that fits your category. His equinovarus was about 6'
plantar and a whopping 52' inversion. His surgeon called me and was almost
at the trans tib surgery stage but wanted to see if I could help. Long story
short, I made him a bivalved afo with a flexible full foot/ankle style
insert that had ski buckle style closure on the anterior section and
required build up exteriorly. He was non-ambulatory initially but became
ambulatory as a result of our treatment. I have photos that I can share if
you'd like. It was by far the largest equinovarus angle I've ever treated
but worked well. Yes I was able to be reimbursed. In Ontario Canada we have
a program called ADP (assistive devices prog) that covers 75% of orthosis
costs assuming they're fabricated a CO.
The best solution I have found is a leather calf lacer AFO with shoes
attached. The metal uprights and lacer support the weight and the shoe is
built to accommodate the deformity. Sometimes the old metal systems work
well with these patients because of the redistribution of pressure. T straps
can be added if the patient has some ankle mobility to reduce or correct the
varus positioning. Total contact AFOs are difficult to balance out depending
on the amount of equino varus present. Skin issues are always a problem even
for limited standing and ambulation when they are in severe fixed
equinovarus.
Custom boots that lace up snug and accommodate the deformity with much
custom formed padding on the interior and a laterally flared base of support
and a slight toe rocker. She would probably still need max assist with a
wheeled walker, however it would have to be monitored frequently. I'm going
to guess she was probably a bit planter flexed as well so there would need
to be elevation enough to bring the ground to her heels. Depending on the
staff would be a gamble. Getting paid would be next to impossible unless
there are private funds available. Just guessing but I would imagine your
cost would probably be in the $1500 category ..oh , and a lot of time.I feel
your pain and hers.
I've done exactly what you're talking about. Its not practical and she wont
be functional with them. This is a surgical problem not an orthotic
solution. The right dr can fix this and THEN you should brace to support and
maintain. Good luck getting paid for a project like that.
I wouldn't do it.
I have done something similar to what you describe twice, but never for a
bilateral user. One was a younger patient, early teenager and one a
geriatric patient. They involved a substantial amount of crepe build ups to
achieve stability. The teenager had a leg length discrepancy and I was able
to mold the crepe in such a way that he could don a shoe and keep some
cosmetic aspect. He used it for daily ambulation. The geriatric patient
never used her's for more than transferring.
I ended up using an anterior shell, not really PTB, on the teenager as it
helped keep him from sliding down and out of the AFO. Both times I used
varus correction strap riveted exterior/posterior then created a slot for it
to enter the brace and create a good line of pull. Hopefully any of that
description gives your some help with your plan. Let me know if I was too
vague or need a better description. It has been about 4 years since I last
fit one, so I cannot remember all the details.
I have made AFO's for similar patients.
I cast them ML neutral and when I mold the plastic I add numerous pieces of
plastic to create a heel under the heel it fits well in the shoes and walks
well. I also use dorsi assist joints to encourage an Achilles stretch.
A common problem, Fixed deformities . take a good mold modify it correctly
with appropriate build ups. Depending on what approach you are going to use
I recommend a two piece anterior door over posterior section. It can be
copoly or polypropylene . I prefer lamination Then laminate it. Then set up
foam build up under the foot to align the tibia. 3 to 5 anterior tilt
according to shoe heel height. Also align
medially and laterally. For foot flat. Then shape to fit shoe . Then
second lamo after. To secure and protect and reinforce first lamo. I made
50 of these at least in my 45 year career . It can also be done as torch
walker style or anterior posterior shell custom crow walker. If you cannot
use a shoe. If you make the foam correctly under the foot you will be able
to shape it to go into the shoe. However It's easier to make a torch
walker. Then-you didnt need to make a anterior door. It laces up the front.
For a nursing home situation this is your best bet . The torch walker is
your best option no shoe headache. Softer nothing like leather . The code
for. Afo . Leather lacer .padding. Lifts. Ect. Good luck. I suggest you
modify everything first then send to have torch walker or crow walker made.
Don't forget weight lines. Side and front of cast.
had a similar situation where a patient was in a coma for a few weeks and
awoke with plantar flexion contractures bilaterally
PT at snf asked about afos
I suggested that we simply take a pair of her tennis shoes and add heel
wedges to both shoes to get the shoes flat on the floor to allow walking in
therapy. She has progressed and I am just about ready to reduce the wedge
for the second time. Original wedges were 3 1/2 at the heels and now down
to about 1 1/2. Or, just get her a pair of cuban heels. Or cowboy boots.
Never did afos. It's working fairly well and made me look really smart.
Our office has made A few similar devices. One to stabilize a nonunion
fracture, One to stabilize a severe equineo varus deformity from a crushing
injury, And one in ambulation for a young woman with arthrogryposis. Two
were of a clamshell design; One thermoplastic and one laminated. And one
was a Mutant design using foam copoly and pro flex - sort of an
Arizona/torch Walker made from plastic. All three were moderately
successful and a raging pain in the neck to fabricate. None were fit in a
skilled nursing facility so as far as I know we actually got paid for all of
them.
I have a patient who has developed severe equino varus deformities
bilaterally which we were unable to correct with dynamic AFOs.
She is in a SNF and is alert and still wants to ambulate and would benefit
from weight bearing and exercise, but her deformities preclude traditional
AFOs. I am wondering if anyone if any of you have tried making total contact
well-padded AFOs to accommodate the deformities with modified soles to allow
weight bearing/ standing and very limited walking. She is not diabetic. Of
course the skin would need to be monitored closely and she would need
assistance standing and would require an assistive device to balance and
ambulate. Please let me know if any of you have attempted such a fitting
experiment. I have significant reservations not to mention doubts regarding
receiving payment. Thanks, Randy McFarland, CPO Fullerton, CA
RESPONSES: Thanks to contributors!
I have a past patient that fits your category. His equinovarus was about 6'
plantar and a whopping 52' inversion. His surgeon called me and was almost
at the trans tib surgery stage but wanted to see if I could help. Long story
short, I made him a bivalved afo with a flexible full foot/ankle style
insert that had ski buckle style closure on the anterior section and
required build up exteriorly. He was non-ambulatory initially but became
ambulatory as a result of our treatment. I have photos that I can share if
you'd like. It was by far the largest equinovarus angle I've ever treated
but worked well. Yes I was able to be reimbursed. In Ontario Canada we have
a program called ADP (assistive devices prog) that covers 75% of orthosis
costs assuming they're fabricated a CO.
The best solution I have found is a leather calf lacer AFO with shoes
attached. The metal uprights and lacer support the weight and the shoe is
built to accommodate the deformity. Sometimes the old metal systems work
well with these patients because of the redistribution of pressure. T straps
can be added if the patient has some ankle mobility to reduce or correct the
varus positioning. Total contact AFOs are difficult to balance out depending
on the amount of equino varus present. Skin issues are always a problem even
for limited standing and ambulation when they are in severe fixed
equinovarus.
Custom boots that lace up snug and accommodate the deformity with much
custom formed padding on the interior and a laterally flared base of support
and a slight toe rocker. She would probably still need max assist with a
wheeled walker, however it would have to be monitored frequently. I'm going
to guess she was probably a bit planter flexed as well so there would need
to be elevation enough to bring the ground to her heels. Depending on the
staff would be a gamble. Getting paid would be next to impossible unless
there are private funds available. Just guessing but I would imagine your
cost would probably be in the $1500 category ..oh , and a lot of time.I feel
your pain and hers.
I've done exactly what you're talking about. Its not practical and she wont
be functional with them. This is a surgical problem not an orthotic
solution. The right dr can fix this and THEN you should brace to support and
maintain. Good luck getting paid for a project like that.
I wouldn't do it.
I have done something similar to what you describe twice, but never for a
bilateral user. One was a younger patient, early teenager and one a
geriatric patient. They involved a substantial amount of crepe build ups to
achieve stability. The teenager had a leg length discrepancy and I was able
to mold the crepe in such a way that he could don a shoe and keep some
cosmetic aspect. He used it for daily ambulation. The geriatric patient
never used her's for more than transferring.
I ended up using an anterior shell, not really PTB, on the teenager as it
helped keep him from sliding down and out of the AFO. Both times I used
varus correction strap riveted exterior/posterior then created a slot for it
to enter the brace and create a good line of pull. Hopefully any of that
description gives your some help with your plan. Let me know if I was too
vague or need a better description. It has been about 4 years since I last
fit one, so I cannot remember all the details.
I have made AFO's for similar patients.
I cast them ML neutral and when I mold the plastic I add numerous pieces of
plastic to create a heel under the heel it fits well in the shoes and walks
well. I also use dorsi assist joints to encourage an Achilles stretch.
A common problem, Fixed deformities . take a good mold modify it correctly
with appropriate build ups. Depending on what approach you are going to use
I recommend a two piece anterior door over posterior section. It can be
copoly or polypropylene . I prefer lamination Then laminate it. Then set up
foam build up under the foot to align the tibia. 3 to 5 anterior tilt
according to shoe heel height. Also align
medially and laterally. For foot flat. Then shape to fit shoe . Then
second lamo after. To secure and protect and reinforce first lamo. I made
50 of these at least in my 45 year career . It can also be done as torch
walker style or anterior posterior shell custom crow walker. If you cannot
use a shoe. If you make the foam correctly under the foot you will be able
to shape it to go into the shoe. However It's easier to make a torch
walker. Then-you didnt need to make a anterior door. It laces up the front.
For a nursing home situation this is your best bet . The torch walker is
your best option no shoe headache. Softer nothing like leather . The code
for. Afo . Leather lacer .padding. Lifts. Ect. Good luck. I suggest you
modify everything first then send to have torch walker or crow walker made.
Don't forget weight lines. Side and front of cast.
had a similar situation where a patient was in a coma for a few weeks and
awoke with plantar flexion contractures bilaterally
PT at snf asked about afos
I suggested that we simply take a pair of her tennis shoes and add heel
wedges to both shoes to get the shoes flat on the floor to allow walking in
therapy. She has progressed and I am just about ready to reduce the wedge
for the second time. Original wedges were 3 1/2 at the heels and now down
to about 1 1/2. Or, just get her a pair of cuban heels. Or cowboy boots.
Never did afos. It's working fairly well and made me look really smart.
Our office has made A few similar devices. One to stabilize a nonunion
fracture, One to stabilize a severe equineo varus deformity from a crushing
injury, And one in ambulation for a young woman with arthrogryposis. Two
were of a clamshell design; One thermoplastic and one laminated. And one
was a Mutant design using foam copoly and pro flex - sort of an
Arizona/torch Walker made from plastic. All three were moderately
successful and a raging pain in the neck to fabricate. None were fit in a
skilled nursing facility so as far as I know we actually got paid for all of
them.
Citation
Randy McFarland, “Severe Equinovarus deformities and ambulation: RESPONSES page 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/237971.
